Helping Patients Navigate Barriers to Cancer Therapies: Sophia Humphreys, PharmD, MHA, BCBBS

Access and affordability are persistent themes in discussions of cancer care, as patients often face obstacles on the road to receiving the most cutting-edge therapies. But there are ways to mitigate cost and access barriers, and providers can help patients navigate them, said Sophia Humphreys, PharmD, MHA, BCBBS, executive director of pharmacy at Providence Health, in an interview with The American Journal of Managed Care® (AJMC®).

In part 1 of the interview, Humphreys shared how pharmacists and clinicians can play a part in improving care access for patients.

This transcript has been edited for length and clarity.

Sophia Humphreys, PharmD, MHA, BCBBS

AJMC: From your perspective, what are the most significant barriers patients face when trying to access cancer therapies, especially immunotherapies and targeted agents?

Humphreys: The 2 most talked about barriers we see are financial toxicity and operational complexity. Especially for high-cost, high-complexity treatments like immunotherapy and targeted treatments, and just the sheer complexity of these treatments, because you need a comprehensive care team and you need a very well-equipped care center. Whether in the acute care setting or in the cancer center or infusion center, all of the above would need a specially trained care team, including your physicians, nurses, lab, pharmacists, and care team. Not all centers are available in every neighborhood. Access to treatment can be largely located in major academic centers or in research centers, which usually are in your metropolitan areas—in bigger cities or moderately sized cities, so access and health equity would come into consideration as well.

For example, regarding high costs, most of your immunotherapy and some of the targeted treatments are in the 6 digits, and a lot of patients have higher deductibles. Especially now, some of the PBMs will not allow pharmaceutical manufacturers' copay cards to apply to the deductible, and this would eat up the patient's deductible really quickly.

And of course, there's the insurance disparity, which is an issue. You can see very obviously that Medicare or Medicaid coverage would be very different from, say, employer-sponsored commercial payers. And especially for lower-income individuals who are on Medicaid, you will see the coverage for immunotherapy is quite different—from the line of therapy allowed to the copayment structures and so forth. For example, a single Medicare beneficiary who is living at 400% of the federal poverty line would have an annual income of $86,388. If they are responsible for 20% of a $400,000 treatment, that would create an enormous financial burden.

There's also the rural access, like we talked about, and these patients, when they live in an area that's far away from research centers, not only don't they get access to these therapies, but also, if you think about all the clinical trials for the newest treatments—for immunotherapies, for targeted treatments—they are conducted in research centers, which, coincidentally, like we talked about, would be in large cities, so health equity and disparity is another consideration.

AJMC: How can oncologists and pharmacists better collaborate to ensure that cost considerations are incorporated early in treatment planning without compromising efficacy or timeliness of care?

Humphreys: A lot of these considerations really start before the treatment plan is finalized, because when we plan coordinated oncology care for all patients within our health system, the entire health care team is involved. This includes oncology pharmacy, the lab, nursing, oncologists, revenue cycle, social work, and so forth. We start with pipeline evaluation to update treatment algorithms and follow NCCN guidelines to assure clinical path adherence. And all formulary decisions would also have a pharmacoeconomic consideration built into the strategy. Our goal is to provide the best quality care, with high efficacy, safety, and tolerability, also at the most reasonable cost to the health system and patients.

Tolerability is an especially important consideration for cancer treatment regimens. Sometimes a highly effective medication can also be highly toxic, and then you are facing cycle disruptions and dosing reduction, and sometimes we must stop therapy due to intolerability of the toxicity.

Once all relevant data are evaluated and all factors considered, the Pharmacy and Therapeutics Committee, as well as your cancer institute (we call them different things, either a quality improvement or clinical institute; they're all cancer treatment-focused expert groups). Those are usually multidisciplinary teams, which make the final decision regarding formulary and treatment algorithm decisions.

And then we would work in a stepwise manner to really focus on the treatment algorithm and to pick the most effective, safe, and reasonable treatment as your first line and so forth. We do follow NCCN Guidelines quite a bit. However, knowing that a lot of the disease states and a lot of the patient-specific cases need to have frontline clinician and patient joint decision-making, which may or may not absolutely fit for all NCCN steps and algorithms. You need to allow some degree of autonomy so that the treatment plan is patient-specific and as cost-effective as possible.

And of course, our team on the frontline, the dispensing team in the frontline—for example, the infusion care team—would also work with foundations and with professional societies or pharmaceutical companies to really help patients, to find financial assistance, and to work on free drug programs, and we call them patient assistance programs, or PAP. There are also medication replacement programs. For example, some of the manufacturers have an agreement with some of the healthcare systems so that if a particular medication was mixed, but the patient cannot take it that day, the medications would be replaced. That reduces both health system costs and patients' out-of-pocket costs.

AJMC: As a pharmacist, how do you help patients navigate the financial assistance landscape, and what tools or resources are most useful in that process?

Humphreys: So we have several approaches. In the beginning, as soon as the therapy plan and the treatment plan come to the pharmacy, we work with our technicians and work with our social workers to see if these medications are covered by the patient's payer. Sometimes we actually can find alternatives—lower-cost alternatives, biosimilars to certain large-molecule products, or the payer-preferred product—sometimes within the same subtherapeutic or treatment subclasses that we can use for the patient.

In addition to that, there are the manufacturer copay programs and also manufacturer prior authorization support. We also have something we call CAREAssist that started with one specific disease state. I remember before, our PA team manager had this huge Excel file in the very beginning. With that development, we now have a dashboard to follow, and it's a lot more sophisticated. We have a tool that's used in a lot of the high-cost, high-impact clinics. It's a multi-step approach where the high-cost medications and prescriptions go to a specific team, and they will work with the payers. They will work with the financial assistant so that when we finally have that team finish working on these prescriptions, which usually takes about 48 to 70 hours on average—which is quite efficient if you think about these high-cost medications, some of them are in the 6 or 7 digits—that way, we minimize the patient's out-of-pocket costs. We minimize the financial burden to the health system, and we maximize the speed from prescription to administration.